The interface between primary and secondary care is increasingly a source of friction, unnecessary workload and frustration. A recent GPonline survey revealed the extent of the problems regarding GP workload, with 83% of respondents saying that limiting the transfer of work from secondary to primary care should be prioritised.
Barriers to effective working across primary and secondary care are varied and complex, frequently arising from cultural differences, inflexible processes, and communication difficulties. They strain working relationships, add to stress, and hinder safe and efficient patient care.
While the government is introducing new measures to tackle the problems, GPs may find inspiration for locally-tailored solutions in a report by the Academy of Medical Royal Colleges (AMRC), discussed below.
Guidance to reduce inappropriate transfer of workload
Existing requirements introduced under the NHS contract in 2017 aim to delineate responsibilities and avoid inappropriate transfer of workload, and the British Medical Association (BMA) provides a useful summary of these requirements. Secondary care providers should:
- Make onward outpatient referrals for immediate or related needs, without referring patients back to GPs.
- Not ask GPs to re-refer patients who do not attend scheduled appointments.
- Manage patient queries and communicate test results directly to patients.
- Send discharge summaries to the GP within 24 hours.
- Send standardised clinic letters electronically, and within 10 days when there are actions for the GP in relation to the patient’s ongoing care.
- Issue medication upon discharge for at least seven days (or as clinically appropriate).
- Issue fit notes at a suitable time (e.g. at discharge), when required, to cover an appropriate period of time.
- Only initiate shared care protocols when the individual GP has accepted clinical responsibility for the patient.
Further clarity was provided by NHS England in guidance on the Responsibility for prescribing between primary and secondary care, and by the AMRC in Onward referral guidance.
However, the GPonline survey highlights the fact that these guidelines are often not followed. As a result, GPs have increasing amounts of administrative work, while patients are frequently left in limbo waiting for information. Many GP appointments are booked by patients purely to ask about delayed secondary care, or about test results, medications and fit notes that should have been provided by the hospital.
BMA: Practice checklist
The BMA provides advice and a template letter pack for GPs to push back on inappropriate hospital requests. Their advice includes:
- Develop a practice policy on how to push back on inappropriate hospital requests.
- Ensure all GPs in the practice are aware of the standards.
- Use BMA template letters when hospitals fail to meet the standards.
- Keep a practice record of all breaches and regularly feedback to the Local Medical Committee.
Government plans to reduce administrative burden
The government’s ‘Delivery plan for recovering access to primary care’ acknowledges the burden on GPs from ‘work generated by issues at the primary-secondary care interface’, and sets out measures to reduce this. Under the plan, Integrated Care Boards (ICBs) must address these four areas:
- Onward referrals within hospitals.
- Complete care (fit notes and discharge letters with ‘clear actions for general practice’).
- Call and recall systems for follow-up tests or appointments.
- Clear points of contact between primary and secondary care (e.g. single outpatient department email for GP practices or primary care liaison officers in secondary care).
ICBs are also tasked with setting up systems to enable GPs and consultant-led teams to discuss and address local challenges at the interface of primary and secondary care. The ICBs are expected to update their public board with progress in October or November 2023.
Initiatives for working together effectively
ICBs have been advised to look at the AMRC report: ‘General practice and secondary care – Working better together’. GPs may also find ideas among the case study examples in the report, which describe local initiatives to improve aspects of culture, communication, and clinical process at the interface of primary and secondary care.
Results have been remarkable, in many cases demonstrating reduced referral rates, fewer hospital stays, more rewarding interactions, and reduced workload in the long term (often after an initial period of more intense effort).
Successful projects have included elements that could be incorporated into practice more widely, summarised as:
- ‘Potential quick wins’, including non-public phone numbers and shared email boxes for ease of communication; outpatient helplines for administrative queries about hospital appointments; education of trainee doctors in completing discharge summaries; guidance on use of fit notes for secondary care clinicians; regular ‘interface groups’ involving GP and secondary care representatives (in various formats, such as MDT huddles, clinical advice meetings, lunch-and-learn sessions); access to electronic health records across the interface; primary care liaison officers to resolve queries; and standardised outpatient clinical letters.
- ‘Drivers for success’, including strong relationships between clinicians in general practice and secondary care; healthcare leaders open to change; an enthusiastic ‘champion’; administrative, IT and financial support; being clinically led, with balanced representation from general practice and secondary care, and tailored to local need; being focused on facilitating dialogue and removing unnecessary administrative steps; having an educational component; considering the impact on clinician workload; and being focused on involving patients in discussions about their care.
If interactions between your practice and secondary care teams are problematic, please contact us for expert and friendly advice at Medical Defense Society.